Ep 140 COVID-19 Part 4 – Protected Intubation

There are many complicated guides on airway management and protected intubation since the COVID-19 pandemic broke. This can be confusing in our rush to develop protocols and guides in our own EDs. In this podcast, part of the COVID-19 EM Cases 5-part series, we aim to simplify protected intubation so that you can adapt it to your ED rapidly. Canada’s leading airway expert, George Kovacs guides us through the general principles and important details of the protected RSI…

This podcast and blog post are based on Level C evidence – consensus and expert opinion. Examples of protocols, checklists and algorithms are for educational purposes and require modification for your particular needs as well as approval by your hospital before use in clinical practice.

This podcast was recorded on March 19th, 2020 and the information within is accurate up to this date only, as the COVID pandemic evolves and new data emerges. The blog post will be updated regularly and we are working on a weekly update via the EM Cases Newsletter which will be replicated on the EM Cases website under ‘COVID-19’ in the navigation bar.

Update March 29th: We know that BVM can aerosolize virus particles, especially when bagging (which is generally not recommended in the COVID era), however BVM is recommended as an option for pre-oxygenation and re-oxygenation after a failed first attempt. A key aspect of the technique to minimize the chances of aerosolization is the type of grip. The “CE” grip is the one handed grip which is not recommended and the “VE” 2-handed grip (with aggressive jaw thrust and the thenar eminences almost touching) is recommended (see image).

Left: “CE” one handed grip not recommended. Right” 2 handed “VE” grip with thenar eminences almost touching is recommended for BVM in the protected RSI

GlideScope ® Spectrum™ with single use [Macintosh-shaped] DVM 3 or 4 blades;

McGrath Mac with single-use Mac size 3 or 4 blades.

If no Macintosh device is available, use hyperangulated video laryngoscopy.

*Using a conventional out-of-package (straight to coudé tip) bougie is not recommended as an adjunct with hyperangulated video laryngoscopy. In experienced hands, a ‘customized’ distally bent bougie, a purposeful made malleable or steerable bougie may be used with hyperangulated video laryngoscopy.

Note that you won’t see an ETCO2 trace unless you gently provide pressure support. Anytime you squeeze the bag there is some risk to aerosolization. The risk of controlled ventilation (6-10 breaths over 1 minute) must be balanced against worsening hypoxemia that results in cardiac arrest.

Place an oral airway and apply your filtered BVM system with 10cm PEEP, 15 LO2 with manual breaths (6-10 over 1 minute). Having a pressure manometer attached to the MDI port to avoid pressures >15 is ideal.

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

Some experts are recommending approaching every COVID patient as an “anticipated difficult airway”, and having a Plan A, B, C that includes VL, SGA, Cric will cover any eventuality. For me, if VL fails my plan B is 2nd generation SGA followed by call to anesthesia for fiberoptic intubation through the SGA. Interested in others’ thoughts.

Great question re anticipated difficult airway. Simple answer is that an awake intubation is relatively contraindicated. We have fallen back to a ‘double set up’ approach. However if you feel it absolutely needs to be considered this should be done under guidance of an anesthesiologist trained to do a protected awake approach. Quite frankly I don’t know of anyone doing this.

1)With tolerating/expecting more hypoxia should we expect we might encounter bradycardia more often during intubation and also think about having atropine on hand or even pretreat?
2) an anesthesia colleague thought that you should choose rocuronium over succinylcholine for intubation due to theoretical risk of fasiculations causing aerosolization. Any thoughts ?

Re preoxygenation, isn’t the bag valve/PEEP-mount-etco2-viral filter-mask set-up going to offer lots of resistance to thh awake patient taking spontaneous breaths?
I understand 15l/min O2 via standard NRBM is aerosol-generating, and in any case many patients will be significantly hypoxic despite being on this before the decision is made to intubate them.

Is ventilator-assisted preoxygenation a superior means for preoxygenating the spontaneously breathing patient? (So long as a good deal came be obtained on a standard NIV mask). What are your thoughts?

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Emergency Medicine Cases (EM Cases) is a free online medical education podcast, medical blog and website dedicated to providing online emergency medicine education and CME for physicians, residents, students nurses and paramedics. We are Canada’s most listened to emergency medicine podcast with thousands of subscribers, well over 6 million podcast downloads since 2010 and are proudly part of the #FOAMed community. In each Main episode podcast 2 or more experts in a particular emergency medicine topic join Dr. Helman in a round-table, case-based discussion on key practice changing clinical emergency medicine topics, which are then carefully edited to maximize your learning. EM Cases’ Journal Jam podcast brings together world-renowned researchers and educators to keep you up to date on key research papers in EM, the EM Quick Hits podcast has 5 minute segments from 10 experts in specific challenging EM topics, and the Best Case Ever podcast has guest experts sharing their tacit knowledge on particularly interesting cases. We also offer the CritCases blog and Waiting to Be Seen blog as well as eBooks, Rapid Reviews Videos of the main episode podcasts, POCUS Cases videos, a Quiz Vault, and interactive courses.
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